Codeine ban: Dextromethorphan a lesser evil?

Following the widespread abuse of codeine and tramadol, especially by youths in Nigeria, the federal government recently placed restrictions on importation of codeine containing cough syrups, directing it should be replaced with dextromethorphan, which is less addictive. Will codeine ban and introduction of dextromethorphan check the abuse of drugs? AJUMA EDWINA OGIRI writes.

Since 2015, codeine became one of the most abused opiates in Nigeria. Thousands of young people in Nigeria are addicted to codeine cough syrup; a medicine that has become a street drug. According to a recent report by the federal government, three million bottles are consumed every day in Northern Nigeria alone.

The menace was brought more to limelight following the recent release of an investigative documentary by BBC: Africa Eye, which showed the extent of codeine addiction in Nigeria. The documentary, which is the result of a five-month in-depth undercover investigation into the plague of addiction to cough mixtures across Nigeria, exposed major ills in the Nigerian pharmaceutical industry.

It also revealed senior figures in Nigeria’s pharmaceutical industry, moving their legally produced products through the back door of their factories and into the hands of drug dealers who sell the sweet tasting addictive opioid for the price of a bottle of cola.

Ban on importation of codeine containing cough syrups

The federal ministry of health recently directed the National Agency for Food and Drug Administration and Control (NAFDAC) to ban with immediate effect further issuance of permits for the importation of codeine as an active pharmaceutical ingredient for cough syrup preparations.
“As the Chief Executive Officer of NAFDAC, what we have decided to do is not to issue permit to any company to bring in codeine, because we issue annual permit, so we have put an embargo on that. We are going to be meeting with the pharmaceutical manufacturing group, the Association of Community Pharmacists of Nigeria (ACPN) and the NDLEA, because drug abuse is a multi-sectoral problem in terms of regulation and enforcement. The embargo will be in place until we are able to have a work plan.

“We have a very big problem in our country and the government has to start adequate regulations at this time. We are supposed to be controlling the importation of drugs, but NAFDAC was removed from the ports. If you remove the agency in charge, which agency will do that? We are not at the point of entry, so I am waiting for the federal government to give us a go ahead,” the Director-General of NAFDAC, Prof. Mojisola Adeyeye, explained.

The ban further led to NAFDAC shutting down the operations of Peace Standard Pharmaceutical ltd., BIORAJ Pharmaceutical Ltd, both in Ilorin, Kwara state, and Emzor Pharmaceuticals Industry, Lagos, as these companies were indicted in the BBC documentary.

According to NAFDAC, “a team of nine officers was sent to carry out an investigational inspection at the companies which were licensed to manufacture codeine-containing syrup, and which were implicated in the BBC documentary on May 2 and 3, 2018.”

The agency added that the team which comprised two officials from Drug and Evaluation Research (DER), and seven from Investigation & Enforcement (I&E), of NAFDAC, and ten mobile police officers were sent to the company to access and monitor from records the utilization, sales and effective distribution of the codeine-containing cough syrups to the end users.

The agency added that the companies refused to cooperate with the officials of NAFDAC to carry out the task.

“Due to insufficient evidence gathered and apparent resistance to provide needed documents during an inspection on May 2, 2018, at the respective companies in Ilorin and Lagos, respectively, it has become necessary to shut down all product lines of the three companies.

“The closure of the three companies is to allow for a full and comprehensive investigation; the three companies, therefore, remain closed.
“The reopening of the manufacturing companies will depend on the level of cooperation that is shown during the comprehensive investigation,’’ Prof. Adeyeye explained.

Dextromethorphan, better option?

The Minister of Health, Prof. Isaac Adewole, has said that: “Codeine containing syrups should be replaced with dextromethorphan,” which according to him is less addictive.
“Dextromethorphan is a cough suppressant used to treat cough, it is also a drug of the morphinan class with sedative, dissociative, and stimulant properties,’’ Adewole noted.

Dextromethorphan is an over the counter medicine that is chemically similar to prescription medicines for pain, like codeine and morphine. It suppresses the central nervous system; brain and spinal cord and is a key ingredient in most over the counter cough medicines. It is also present in other medications and can cause death in very high doses. It can also make people ‘high’ like codeine, according to experts.

Speaking to Blueprint Weekend, Pharmacist Johnson Ani, said from experience at the community pharmacy level, patent stores try not to give codeine containing syrups to patients, and also make it less available to them.

According to him “even when patients can’t access codeine containing syrups, they have been able to get some level of ‘highness’ under cough syrups that don’t contain codeine; that is cough expectorant, and dextromethorphan falls in this class of some similarities with codeine. It doesn’t have the same impact as codeine, but it is something that can be resorted to if people cannot access codeine.”

Speaking on their similarities, he said “Codeine and dextromethorphan have similar sedative effect. Dextromethorphan also has stimulant properties just like codeine; that is why people abuse codeine. It also comes from the same morphine plant as codeine. So, it has the tendency of causing same addictive, stimulant and sedative effect as codeine. It may not be as high as codeine, but once people cannot access codeine, it is something they can resort too.

“In normal doses both codeine and dextromethorphan act on the central nervous system, and dextromethorphan produces more psychological effect and dependence than codeine. But it has less physical addiction when compared with codeine.

“The only difference is codeine suppresses the respiratory system, while dextromethorphan doesn’t have that much effect on the respiratory system, except on rare occasions. Dextromethorphan is more like a lesser evil,” he further explained.

The American College of Medical Toxicology said symptoms of taking too much dextromethorphan are dependent on the amount ingested.
“Symptoms range from feeling more stimulated to euphoria, hallucinations, out of body experiences, coma and even death. Symptoms begin within a half hour of taking dextromethorphan and can last up to six hours or more.”

How feasible is codeine ban?
The National Chairman of the Association of Community Pharmacists of Nigeria (ACPN), Dr Albert Kelong Alkali, said the ban on codeine will not do much except the open drug markets in the country are closed and the National Drug Distribution Guidelines implemented.

Reacting to the ban, some Nigerians took to twitter with one person, Wale Anigilaje, saying: “Is it not disappointing that the Body of Pharmacists in Nigeria and the regulators do not see the “codeineTramadol epidemic” as an opportunity to prevail on the FG to fix the Chaotic Drug distribution in Nigeria? NO – we have allowed them an easy way out, a Lazy man approach.

“The real black market would take over for criminal-gang traders and the addict would go underground. Codeine would become very expensive and Junkies would become more desperate to raise the Money to buy the stuff. Marijuana and Cocaine are banned but they are in our midst.”
With porous borders in Nigeria and most addicts patronising the black market, will the ban on codeine deprive local manufacturers and give more money to those in the black market?

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